Clinician Service Clinician Intake FormClinician Intake Form Client Name:* Address: Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Phone Number:* E-mail:* Parent or Advocate Name What is Your Care Giver Contact Info If Known? Do You Have an HCBS Waiver Service?*YesNoNot Sure Do you have a Smile Broker?YesNo What do you hope for this individual? reCAPTCHASubmitReset